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Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 14 GLC-01252
GROUP lOnG-teRm disability claim(Please see FRaUd nOtices attached)
EMPLOYER GROUPPOLICYNO.
______________________________________________________________________ _____________________________
emPlOyeR -formcompletioninformation
nOtice OF claim - instructions
A. completetheemployer’s portion in fullandreturn this portiontoaddressaboveorfaxtothenumberabove
include d Copyofenrollmentcard(ifemployeecontributestopremium)
d Copyofapprovedmedicalevidenceofinsurabilityifrequiredattimeofenrollment
d IfWorkers’Compensationclaimfiled,includecopyofFirstReportofAccidentandthedecision
B. Give remaining part of form to claimant for completion
The Lincoln National Life Insurance Company, PO Box 2609, Omaha, NE 68103-2609toll free (800) 423-2765 Fax (877) 843-3950www.LincolnFinancial.com
Page 2 of 14 GLC-01252
long-term disability claim employer’s statement
to be completed by the employer
Thisclaimisfor(Employee’sNameandAddress) SocialSecurityNumber DateofBirth
a. information about the employer
Company’sName GroupPolicyNumber ClassNumber
Address(Street,City,State,Zip) Telephone:Fax:
Nameandaddressofdivisionwhereemployeeworks(ifdifferentfromabove) Telephone:Fax:
b. information about the employeeDateemployeewashired(Month,Day,Year)
Dateemployeebecameinsuredunderthisplan?Dateemployeebecameinsuredunderpriorplan?
Whatwastheemployee’sregularlyscheduledworkweek?________hoursperweek________hoursperday
c. information needed for withholding and reporting taxes
Doesemployeecontributepost-taxdollarstowardthepremium? Yes NoIfyes,whatpercentispaidbytheemployee?________%if you leave this section blank, we will assume it is 100% employer contribution and calculate Fica taxes accordingly.
d. information about the claim
Werethereanychangestotheemployee’sjobresponsibilitiesduetothedisablingconditionbeforetheemployeebecamefullydisabled?YesNoIfyes,whatwerethechangesandwhenweretheymade?
Whatwastheemployee’spermanentjobonhisorherlastdayatwork? Howlonghadtheemployeebeeninthisjob?
Lastdayemployeeactuallyworked(Month,Day,Year)
Onthatday,didtheemployeeworkafullday?YesNoIfno,howmanyhourswereworked?
Whydidemployeestopworking? Istheemployee’sconditionworkrelated?YesNo
HasaclaimbeenfiledwithWorkers’Compensation?YesNoIfyes,sendinitialreportofillnessorinjuryandawardnotice.Name,addressandtelephonenumberofyourcompensationcarrier
Name,addressandtelephonenumberofyourmedicalinsurancecarrier
e. information about your pension plan(donotcompleteformaternityclaim) (For Lincoln Financial to complete)Doyouhaveapensionplan?YesNo
Ifyes,whattype? Definedbenefit 401(k) Other:(specify) Definedcontribution Profitsharing
Istheemployeeeligibleforyourpensionplan?YesNoIfno,why?
Ifeligible,doestheemployeeparticipate?YesNoIfno,why?
Iftheemployeeisparticipating,whenisheorsheeligibleforbenefitsundertheplan?(Month,Day,Year)
nOte: if any portion of this pension benefit is attributable to the employee’s contribution, please provide details including the percentage of his/her contribution to the total contribution. this should include a copy of the contract.
F. information about your rehire or return-to-work policies
Doesyourcompanyhavearehireorreturn-to-workpolicyfordisabledemployees?YesNo
Whatisthenameandtitleofthemanagerweshouldcontactifweidentifyarehabilitationorreturn-to-workoption?
G. information about the employee’s salary
Theemployee(Checkallthatapply)ispaidhourly(whatisthehourlyrate?)$________________________issalariedreceivescommissionsreceivesbonuses
Willemployeefilefordisabilitybenefitsprovidedbyanyemployer/employeelabormanagement,statedisabilityorunionwelfareplan?YesNoIfyes,whatistheweeklyamount?$_____________-______Whendobenefitsbegin?_________________End?_________________
Isthisemployeeeligibleforsalarycontinuation?YesNoIfyes,whatistheweeklyamount?$___________________Whendobenefitsbegin?_________________End?_________________
(Continuedonnextpage)
Page 3 of 14 GLC-01252
Reporting the employee’s basic monthly earnings
Findthedefinitionofbasicmonthlyearningsthatmatchesyourcontractforthisemployeeandfollowtheinstructionsgiven.
definitions of basic monthly earnings
a. salaryonly(nocommissions,bonuses,etc.),completequestion1belowb. previousyear’sW-2form,completequestion5below(attachW-2)c. soleproprietor,completequestion8belowd. previousyear’sK-1form,completequestion6below(attachK-1)
e. salaryandcommissions,completequestions1and3belowf. salary,commissionsandbonuses,completequestions1,3and4belowg. salaryanddeferredcompensation,completequestions1and2belowh. salary,deferredcompensationandcommissions,completequestions1,2and3belowi. salary,deferredcompensation,commissionsandbonuses,completequestions1,2,3and4belowj. salaryandK-1earnings,completequestions1and6below
k. W-2withdeferredcompensation,completequestions2and5belowl. partnershipagreement,completequestion7belowm. teacher’scontract,completequestion1belown. anyotherdefinition,completequestion9below
1) Onthelastdayemployeeworked,whatwashisorherbasicmonthlysalary?(Divideannualsalaryby12ormultiplyweeklysalaryby52anddivideby12.Teachersdivideannualsalaryby12) 1_____________________
2) Onthelastdaytheemployeeworked,whatwashisorhermonthlypre-taxcontributiontoyourdeferredcompensationplan? 2_____________________
3) Howmuchhadtheemployeereceivedincommissionsinthe12months(ortheperiodofemploymentiflessthan12months)immediatelyprecedingthelastdayworked?$____________________.Dividethisnumberby 3_____________________12,orthelengthofemploymentiflessthan12months,tofindtheaveragemonthlycommissions.
4) Howmuchhadtheemployeereceivedinbonusesinthe12months(ortheperiodofemploymentiflessthan12months)immediatelyprecedingthelastdayworked?$____________________.Dividethisnumberby12, 4_____________________orthelengthofemploymentiflessthan12months,tofindtheaveragemonthlybonuses.
5) Whatweretheemployee’searningsasshownontheW-2formoftheyearimmediatelyprecedingthedisability? 5_____________________
6) Whatweretheemployee’searningsasshownontheK-1formoftheyearimmediatelyprecedingthedisability? 6_____________________
7) Asofthelastdaytheemployeeworked,whatwerethebudgetedannualearningsasdeterminedbythewrittenpartnershipagreementineffect?(Donotincludedividends,interestorreturnofcapital)$____________________. 7_____________________
8) Asofthelastdaytheemployeeworked,whatwasthesoleproprietor’sannualnetprofit(1040ScheduleCgrossincomeminustotaldeductionsminusdepreciation)averagedoverthe3yearsimmediatelyprecedingthedisabilityortheperiodofsoleproprietorshipiflessthan3years? 8_____________________
9) Fordefinitionsotherthanthoseabove,calculatethemonthlyearningsastheyaredefinedinyourcontract.Ifearningsarebasedonsalaryasexpressedonaparticulardocument,sendusacopyofthedocument. 9_____________________
H. Required attachments and signature
Iftheemployeecontributestothepremiums,attachacopyoftheenrollmentform.
IfsalaryisbasedonaW-2,K-1,1099,orasimilardocument,attachacopyofthedocument.
Ifyouhavemedicalinformationfromtheemployee’sfilerelatingtothisdisability,pleaseattachcopies.
Ifaworkers’compensationclaimisfiled,sendinitialreportofinjuryorillnessandawardnotice.
Nameofpersoncompletingthisform(Ifthisclaimisapprovedfordisabilitybenefits,thebenefitcheckwillbesenttotheemployeewithacarboncopytoyou.)
X _____________________________________________________________ _________________________________________ ____________________Signature Title Date
Page 4 of 14 GLC-01252
long-term disability claim Job analysis
to be completed by the employee’s supervisor
this claim is for (employee’s name)
Employee’sSocialSecurityNumber DateofDisability(Month,Day,Year)
a. General information about the employee’s job
JobTitle Minimumeducationortrainingrequired
Doestheemployeeperformsupervisoryfunctions?YesNoIfyes,howmanypeoplearesupervised?___________________________Describejobduties.
Checktheitemsbelowthatrelatetotheemployee’sjob.Usethesedefinitionsforthefrequencyofoccurrence:Occasionallymeansthepersondoestheactivityupto33%ofthetime.Frequentlymeansthepersondoestheactivity34%to66%ofthetime.continuouslymeansthepersondoestheactivity67%to100%ofthetime.
Occasionally Frequently continuouslyRelatetoothers
Writtenandverbalcommunication
Reasoning,mathandlanguage
Makesindependentjudgments
Whichofthefollowingdescribetheemployee’sworkingenvironment?Checkallthatapply.Unprotectedheights Changesintemperatureorhumidity Exposuretodust,fumesandgasesBeingnearmovingmachinery Drivingautomotiveequipment OtherhazardsIstheemployeerequiredtotravel?YesNoIfyes,completethefollowinginformation:Howdoestheemployeetravel?(Automobile,plane,train,etc.)Wheredoestheemployeetravel? Whatpercentofthetimedoestheemployeetravel?
b. information about the physical aspects of the employee’s jobChecktheitemsbelowthatrelatetotheemployee’sjobandcompletetheinformationrequested.Usethesedefinitionsforthefrequencyofoccurrence:
Occasionallymeansthepersondoestheactivityupto33%ofthetime.Frequentlymeansthepersondoestheactivity34%to66%ofthetime.continuouslymeansthepersondoestheactivity67%to100%ofthetime.
activity Frequency of OccurrenceOccasionally Frequently continuously
Standing
Walking
Sitting
Balancing
Stooping
Kneeling
Crouching
Crawling
Reaching/workingoverhead
Climbing:
Stairs
Numberofstairs:___________ Ladders describe activity Weight
HeightofLadder:___________
Pushing ___________________________________ ___________lbs.
Pulling ___________________________________ ___________lbs.
Lifting/carrying ___________________________________ ___________lbs.
(Continuedonnextpage)
Page 5 of 14 GLC-01252
can the job be performed by alternating sitting and standing?YesNoDoesthejobrequireusingthefeettooperatefootcontrols?YesNoIfyes,onwhattypeofequipment?Howimportantisgoodvisioninthejob?
Whatarethemajortasksrequiringuseofoneorbothhands? OneHand BothHands
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
c. information about the job as it relates to the disabilityCanthejobbemodifiedtoaccommodatethedisabilityeithertemporarilyorpermanently?YesNoIfyes,explain
Isitpossibletooffertheemployeeassistanceindoingthejob(throughuseoftechnologyorpersonalassistanceforexample)?YesNoIfyes,explain
d. attachments and signature (Attachacopyoftheemployee’sjobdescription)
Nameofpersoncompletingthisform
X _______________________________________________________ _____________________________________ __________________Signature Title Date
Telephone Fax
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 6 of 14 GLC-01252
GROUP lOnG-teRm disability claim aPPlicatiOn
emPlOyee -formcompletioninformation
aPPlicatiOn FOR GROUP ltd - instructions
A. complete and sign the authorization on the reverse side of this page.Thiswillallowourinsurancecarrierortheirrepresentativetosecureadditionalinformation(ifnecessary)tomakeadecisiononyourrequestforbenefitpayments(donotdetach).
B. complete employee claim statement in full.
attach d AcopyofSocialSecurityandotherincomeentitlementawards(orforwardwhenreceived)
C. Give this authorization and attached claim application to the physician treating you(ifmorethanone,obtainotherformsforcompletionfromemployer).Instructyourattendingphysiciantosendhisstatementalongwithyourstotheinsurancecarrier.
D. WhenthoseformsarereceivedbytheInsuranceCompany,theywilladviseyouofyoureligibilityforbenefitsorofanyadditionalinformationthatmaybeneeded.
DoNotDetach
The Lincoln National Life Insurance Company, PO Box 2609, Omaha, NE 68103-2609toll free (800) 423-2765 Fax (877) 843-3950www.LincolnFinancial.com
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 7 of 14 GLC-01252
Disability
aUtHORiZatiOn FOR Release OF inFORmatiOn
1. i (the undersigned) authorizeanyphysician,medicalprofessional,pharmacistorotherproviderofhealthcareservices,hospital,clinic,othermedicalormedicallyrelatedfacility;insuranceorreinsurancecompany;governmentagency;departmentoflabor;acquaintance;grouppolicyholder;employer;orpolicyorbenefitplanadministratortoreleaseinformationfromtherecordsof:
Claimant/PatientName:______________________________________________________________________________________(Last) (First) (Middle)
DateofBirth:______________________________________ SocialSecurityNumber:_________________________________
2. Informationtobereleased:
d dataorrecordsregardingmymedicalhistory, treatment,prescriptions,consultations [includingmedicalandpsychologicalreports,records,charts,notes(excludingpsychotherapynotes),x-rays,filmsorcorrespondence,andanymedicalconditionImaynowhaveorhavehad];
d anyinformationregardinginsurancecoverage;and
d anyinformation,dataorrecordsregardingmyactivities(includingrecordsrelatingtomySocialSecurity,Workers’Compensation,RetirementIncome,financial,earningsandemploymenthistory).
3. Informationtobereleasedto: TheLincolnNationalLifeInsuranceCompanyPOBox2609Omaha,NE68103-2609
4. IunderstandtheinformationobtainedbyuseofthisAuthorizationwillbeusedbyTheLincolnNationalLifeInsuranceCompany(“Company”)toevaluatemyclaimfordisabilitybenefits.TheCompanywillonlyreleasesuchinformation:
d toitsreinsurer,orotherpersonsororganizationsperformingbusinessorlegalservicesinconnectionwithmyclaim(s);or
d toavendor,approvedbythecompany,whichspecializesintheapplicationforSocialSecurityDisabilityBenefits
d tovendors/consultantsprovidingtheclaimantwithwellness,disabilityorleaverelatedservicesaspartofanemployersponsored benefitplan
d totheemployerforself-insureddisabilityplans;or
d asotherwisemayberequiredbylaworasImayfurtherauthorize.
IfurtherunderstandthatrefusaltosignthisAuthorizationmayresultinthedenialofbenefits.
5. Iunderstandtheinformationusedordisclosedmaybesubjecttore-disclosurebytherecipientandmaynolongerbeprotectedbythefederalHIPAAPrivacyRule.ForColoradoclaims,thedisclosedinformationmaynotberedisclosedorreusedbytherecipientunderColoradolaw.
6. IunderstandthatImayrevokethisAuthorizationinwritingatanytime,excepttotheextent:
1. theCompanyhastakenactioninrelianceonthisAuthorization;or
2. theCompanyisusingthisAuthorizationinconnectionwithacontestableclaim.Ifwrittenrevocationisnotreceived,thisAuthorizationwillbeconsideredvalidforaperiodoftimenottoexceed24monthsfromthedateofmysignaturebelow.ToinitiaterevocationofthisAuthorization,directallcorrespondencetotheCompanyattheaboveaddress.
7. AphotocopyofthisAuthorizationistobeconsideredasvalidastheoriginal.
8. IunderstandIamentitledtoreceiveacopyofthisAuthorization.
siGnatURe:___________________________________________________________ date:___________________________Claimant/legalrepresentative(Nearestrelative,legalguardian,orappointedrepresentativetosignonlyifclaimant/patientisaminor,legallyincompetent,ordeceased.)Powerofattorneyorguardianshipmustbeattached.
PRINTNAME:___________________________________________________________
RelationshiptoClaimant/Patientofpersonal/legalrepresentativesigningforClaimant/Patient: ________________________________
ADDRESS:_________________________________________________________ PHONENO: ___________________________(Street)
_________________________________________________________(City) (State) (ZipCode)
The Lincoln National Life Insurance Company, PO Box 2609, Omaha, NE 68103-2609toll free (800) 423-2765 Fax (877) 843-3950www.LincolnFinancial.com
Page 8 of 14 GLC-01252
FRaUd nOtices. For your protection, certain states require that the following notices appear on this form.
alaska.Apersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveaninsurancecompanyfilesaclaimcontainingfalse,incompleteormisleadinginformationmaybeprosecutedunderstatelaw.
arizona.ForyourprotectionArizonalawrequiresthefollowingstatementtoappearonthisform.Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossissubjecttocriminalandcivilpenalties.
arkansas, louisiana, Rhode island and West Virginia.Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenefitorknowinglypresentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.
california.ForyourprotectionCalifornialawrequiresthefollowingtoappearonthisform:Anypersonwhoknowinglypresentsafalseorfraudulentclaimforthepaymentofalossisguiltyofacrimeandmaybesubjecttofinesandconfinementinstateprison.
colorado. It is unlawful to knowingly provide false, incomplete, or misleading facts or information to aninsurancecompanyforthepurposeofdefraudingorattemptingtodefraudthecompany.Penaltiesmayincludeimprisonment,fines,denialof insuranceandcivildamages.Any insurancecompanyoragentofan insurancecompanywho knowingly provides false, incomplete, ormisleading facts or information to a policyholder orclaimantfor thepurposeofdefraudingorattemptingtodefraudthepolicyholderorclaimantwithregardtoasettlementorawardpayablefrominsuranceproceedsshallbereported to theColoradoDivisionofInsurancewithintheDepartmentofRegulatoryAgencies.
delaware.Anypersonwhoknowingly,andwithintenttoinjure,defraudordeceiveanyinsurer,filesastatementofclaimcontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.
district of columbia.Itisacrimetoprovidefalseormisleadinginformationtoaninsurerforthepurposeofdefraudingtheinsureroranyotherperson.Penaltiesincludeimprisonmentand/orfines.Inaddition,aninsurermaydenyinsurancebenefitsiffalseinformationmateriallyrelatedtoaclaimwasprovidedbytheapplicant.
Florida.Anypersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurerfilesastatementofclaimorapplicationcontaininganyfalse,incomplete,ormisleadinginformationisguiltyofafelonyofthethirddegree.
idaho.Anypersonwhoknowingly,andwithintenttodefraudordeceiveanyinsurancecompany,filesastatementorclaimcontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.
indiana.Apersonwhoknowinglyandwithintenttodefraudaninsurerfilesastatementofclaimcontaininganyfalse,incomplete,ormisleadinginformationcommitsafelony.
Kentucky.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesa statement of claim containing anymaterially false information or conceals, for the purpose ofmisleading,informationconcerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrime.
maine.Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompanyforthepurposeofdefraudingthecompany.Penaltiesmayincludeimprisonment,finesoradenialofinsurancebenefits.
maryland.Anypersonwhoknowinglyandwillfullypresentsafalseorfraudulentclaimforpaymentofalossorbenefitorknowinglyandwillfullypresentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.
minnesota.Apersonwhofilesaclaimwithintenttodefraudorhelpscommitafraudagainstaninsurerisguiltyofacrime.
new Hampshire.Anypersonwho,withapurposetoinjure,defraudordeceiveanyinsurancecompany,filesastatementofclaimcontaininganyfalse, incompleteormisleadinginformationissubject toprosecutionandpunishmentforinsurancefraud,asprovidedinRSA638:20.
Page 9 of 14 GLC-01252
new Jersey.Anypersonwhoknowinglyfilesastatementofclaimcontaininganyfalseormisleadinginformationissubjecttocriminalandcivilpenalties.
new mexico.Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenefitorknowinglypresentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttocivilfinesandcriminalpenalties.
new york.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesanapplicationfor insuranceorstatementofclaimcontaininganymateriallyfalse informationorconcealsforthepurposeofmisleading,informationconcerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrimeandsubjecttoacivilpenaltynottoexceedfivethousanddollarsandthestatedvalueoftheclaimforeachsuchviolation.
Ohio.Anypersonwho,withintenttodefraudorknowingthatheisfacilitatingafraudagainstaninsurer,submitsanapplicationorfilesaclaimcontainingafalseordeceptivestatementisguiltyofinsurancefraud.
Oklahoma.Anypersonwhoknowingly,andwith intent to injure,defraudordeceiveany insurer,makesanyclaimfortheproceedsofaninsurancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.
Oregon.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherperson:(1)filesanapplicationforinsuranceorstatementofclaimcontaininganymateriallyfalseinformation;or,(2)concealsforthepurposeofmisleading,informationconcerninganymaterialfact,mayhavecommittedafraudulentinsuranceact.
Pennsylvania.Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesanapplicationforinsuranceorstatementofclaimcontaininganymateriallyfalseinformationorconcealsforthepurposeofmisleading,informationconcerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrimeandsubjectssuchpersontocriminalandcivilpenalties.
Puerto Rico.Anypersonwhoknowinglyandwiththeintentionofdefraudingpresentsfalseinformationinaninsuranceapplication,orpresents,helps,orcausesthepresentationofafraudulentclaimforthepaymentofalossoranyotherbenefit,orpresentsmorethanoneclaimforthesamedamageorloss,shallincurafelonyand,uponconviction,shallbesanctionedforeachviolationwiththepenaltyofafineofnotlessthanfivethousanddollars($5,000)andnotmorethantenthousanddollars($10,000),orafixedtermofimprisonmentforthree(3)years,orbothpenalties.Shouldaggravatingcircumstancesarepresent,thepenaltythusestablishedmaybeincreasedtoamaximumoffive(5)years,ifextenuatingcircumstancesarepresent,itmaybereducedtoaminimumoftwo(2)years.
tennessee and Washington.Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompanyforthepurposeofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.
texas.Anypersonwhoknowinglypresentsafalseorfraudulentclaimforthepaymentofalossisguiltyofacrimeandmaybesubjecttofinesandconfinementinstateprison.
FOR all OtHeR states eXclUdinG cOnnecticUt, Kansas, and ViRGinia.Apersonmaybecommittinginsurancefraud,ifheorshesubmitsanapplicationorclaimcontainingafalseordeceptivestatementwithintenttodefraud(orknowingthatheorsheishelpingtodefraud)aninsurancecompany.
Page 10 of 14 GLC-01252
long-term disability claim employee’s statement
to be completed by the employee
a. information about you
LastName First MiddleInitial
Address City State/Province Zip
Telephone SocialSecurityNumber
DateofBirth(Month,Day,Year) Height Weight RtHandedLt.Handed
MaleFemale
SingleMarried
WidowedDivorced
YourEmployer(includedivisionifapplicable)
Occupation
b. information about your family(requiredtodetermineyoureligibilityforSocialSecuritybenefits)
Spouse’sName(Last,First)
Spouse’sSocialSecurityNumber DateofBirth(Month,Day,Year) Isyourspouseemployed?YesNo
Childrenunderage25:Name(Last,First) DateofBirth(Month,Day,Year)
c. information about the condition causing your disability1. Forpregnancyorillness,answerthefollowingquestions:
Whatwereyourfirstsymptoms?
Whendidyoufirstnoticethem? Dateyouwerefirsttreatedbyaphysician(Month,Day,Year)
2. Foraninjury,answerthefollowingquestions:
Whereandhowdidtheinjuryoccur?
Datetheinjuryoccurred(Month,Day,Year) Dateyouwerefirsttreatedbyaphysician(Month,Day,Year)
3. Forillnessorinjury,answerthefollowingquestions:
Whyareyouunabletowork?
Beforeyoustoppedworking,didyourconditionrequireyoutochangeyourjoborthewayyoudidyourjob?YesNoIfyes,explain
Isyourconditionrelatedtoyouroccupation?YesNoIfyes,explain
Haveyoufiled,ordoyouintendtofileaWorkers’Compensationclaim?YesNo
Doyourequireanotherperson’sactive,hands-onhelptosafelyperformactivitiesofdailyliving?YesNoIfyes,pleaseexplainwhatkindofhelpyoureceiveandwhoprovidesit:
d. information about the disability
Lastdayyouworkedbeforethedisability(Month,Day,Year)
Didyouworkafullday?YesNoIfno,explain
Dateyouwerefirstunabletowork?(Month,Day,Year)
Haveyoureturnedtowork?YesParttime(date)_____________Fulltime(date)_____________No
Ifyouhavenotreturnedtowork,doyouexpectto?YesParttime(date)_____________Fulltime(date)_____________No
Areyoucurrentlyself-employedorworkingforanotheremployer?YesNoIfso,givedetails.
(Continuedonnextpage)
Page 11 of 14 GLC-01252
e. information about physicians and hospitals
Firstmedicalattentionforthecurrentdisabilitywasgivenby(completebelow):Doctor’sName Telephone:
Fax:Specialty
Address(Street,City,State,Zip) DatesSeenTo
Listallotherphysiciansandhospitalsyouhaveseenforthiscondition:Doctor’sName Telephone:
Fax:Specialty
Address(Street,City,State,Zip) DatesSeenTo
Doctor’sName Telephone:Fax:
Specialty
Address(Street,City,State,Zip) DatesSeenTo
Doctor’sName Telephone:Fax:
Specialty
Address(Street,City,State,Zip) DatesSeenTo
Hospital Telephone:Fax:
Specialty
Address(Street,City,State,Zip) DatesofConfinementTo
Haveyoueverhadthesameorasimilarconditioninthepast?YesNoIfyes,completethefollowingconcerningyourpasttreatment:Doctor’sName Telephone:
Fax:Specialty
Address(Street,City,State,Zip) DatesSeenTo
Hospital Telephone:Fax:
Specialty
Address(Street,City,State,Zip) DatesofConfinementTo
F. information about other disability income(Checktheotherincomebenefitsyouarereceivingorareeligibletoreceiveasaresultofyourdisabilityandcompletetheinformationrequested.)
SourceofIncome Amount (wk.,mon.) Dateclaimwasfiled Datepaymentsbegan Datepaymentsended
SocialSecurityRetirement $________________ /
SocialSecurityDisability/Yourself $________________ /
SocialSecurityDisability/Dependents $________________ /
CanadianPensionPlan $________________ /
Workers’Compensation $________________ /
StateDisability $________________ /
Pension/Retirement $________________ /
Pension/Disability $________________ /
ShortTermDisability $________________ /
Unemployment $________________ /
No-FaultInsurance $________________ /
RailroadRetirement $________________ /Other(includeindividualorgroupbenefits): $________________ /
G. information about income tax withholdingIfyourrequestforbenefitsisapproved,shouldTheLincolnNationalLifeInsuranceCompanywithholdincometaxesfromyourbenefitchecks?YesNoIfyes,howmuchshouldbewithheldfromeachcheck.Federaltaxes(minimumis$88.00permonth)$_____________.00H. signature(Requiredforallclaims)
UnderwhatotherTheLincolnNationalLifeInsurancepoliciesareyoucurrentlycovered?TheaboveStatementsaretrueandcompletetothebestofmyknowledgeandbelief.IhavereadandunderstandtheattachedFraudWarningstatements.
X ______________________________________________________________________________ __________________________________ SignatureofEmployee Date
Page 12 of 14 GLC-01252
long-term disability claim Physician’s statementThisformshouldbecompletedbythephysicianwhowastreatingtheclaimantwhenheorshelastworked.
ToBeCompletedByTheAttendingPhysician
a. General information
Thisclaimisfor(Patient’sName)
Patient’sSocialSecurityNumber Height Weight BloodPressure DateofBirth(Month,Day,Year)
PrimaryDiagnosisincludingICD9orDSMcode
b. complete this section for normal pregnancy, then go to section e.
Whatwasthedateofthelastmenstrualperiod? Whatistheexpecteddateofdelivery?
Whatistheexpectedlengthofpostpartumrecovery? Whatwasthefirstdateoftreatment? Whatwasthelastdateoftreatment?
c. complete this section for all conditions except normal pregnancy.
Symptoms
ObjectiveFindings
Aretheresecondaryconditionscontributingtothedisability?YesNoIfyes,whatarethey?(PleaseincludeICD9orDSMcode.)
Ifthisisacardiaccondition,whatisthefunctionalcapacity?(AmericanHeartAssociation)
Class1-NolimitationClass2-Slightlimitation
Class3-MarkedlimitationClass4-Completelimitation
Whendidsymptomsfirstappear? Dateofthepatient’sfirstvisit(Month,Day,Year)
Dateyoubelievethepatientwasfirstunabletowork(Month,Day,Year)
Dateofthepatient’slastvisit(Month,Day,Year)
Howoftendoyouseethepatient?
Isthepatient’sconditionworkrelated?YesNoIfyes,explain:
Hasthepatientundergonesurgery?YesNoIfyes,givedate,procedureandresult.
Ifno,doyouexpectsurgerytobeperformedinthefuture?YesNoIfyes,givedateandtypeofsurgery.
Whatmedicationisthepatientcurrentlytaking?
Pleaseindicateothertypesandfrequenciesoftreatment.
Hasthepatientbeenreferredtoamedicalrehabilitationortherapyprogram?YesNoIfyes,givedetails.
Haveyoureferredthepatientforothertypesofconsultations?YesNoIfyes,givedetails.
Hasthepatientbeenhospitalconfined?YesNoIfyes,completethefollowing:
NameofHospital
Address DatesofConfinementthrough
Page 13 of 14 GLC-01252
d. information about the patient’s inability to workBrieflydescriberestrictionsandlimitations.
Restrictions(WhatthepatientSHOULDNOTdo)
Limitations(WhatthepatientCANNOTdo)
Whatisyourprognosisforrecovery?
Haspatientachievedmaximummedicalimprovement?YesNoIfno,completethefollowing:
Howsoondoyouexpectfundamentalchangesinthepatient’smedicalcondition?1-2months 5-6months3-4months morethan6monthsGivedetailsconcerningexpectedimprovementordeterioration:
Inaneighthourworkday,claimantcan:(Circlefullhourlycapacityforeachactivity)Sit 1 2 3 4 5 6 7 8Stand 1 2 3 4 5 6 7 8Walk 1 2 3 4 5 6 7 8
Arethererestrictionsin: Yes No Comments
Lifting/Carrying ___________________________________________________________________________
Useofhandsinrepetitiveactions ___________________________________________________________________________
Useoffeetinrepetitivemovements ___________________________________________________________________________
Bending ___________________________________________________________________________
Squatting ___________________________________________________________________________
Crawling ___________________________________________________________________________
Climbing ___________________________________________________________________________
Reachingaboveshoulderlevel ___________________________________________________________________________
Other(pleasespecify) ___________________________________________________________________________
Whendoyouexpectclaimanttoreturntopriorleveloffunctioning?
Wouldyourecommendvocationalrehabilitationforthispatient?YesNo
Hasyourpatienthadlossofcognitivefunctioning?“Cognitiveimpairment”meansapermanentdeteriorationorlossofcognitiveorintellectualcapacityandrequiresanotherperson’shands-onhelporverbalcuestopreventharmtoselforothersduetoimpairmentYesNoIfyes,pleaseexplainandprovidesupportingmedicaldocumentationandtesting:
Basedonyourobservationsofthispatient,medicalhistoryandcondition,hasyourpatientlosttheabilitytosafelyandcompletelyperformActivitiesofDailyLiving(ADLs)withoutanotherperson’sactivehands-onhelpwithallormostoftheactivity:
ADL Dateonwhichassistancewasfirstrequiredandreceived
Bathing_______________(washingselfintub,showerorbyspongebath,withorw/oequipment)
Dressing______________(puttingon,takingoffgarmets,bracesoranyartificiallimbsnormallyworn)
Toileting______________(gettingto,from,onandofftoilet;andperformingrelatedpersonalhygiene)
Transferring___________(movingin&outofbed,chairoranywheelchair,withorw/oequipment)
Continence____________(voluntarilymaintainingcontrolofbladderandbowelfunction)
Eating________________(gettingnourishmentintoone’sbodybyanymeans(table/trayorspecialequipment)
IftheclaimanthaslosttheabilitytoperformADLslistedabove,pleaseprovideanysupportingmedicaldocumentationandtesting.
IfthepatienthaslosttheabilitytoperformanyADLslistedabove,doyouexpectthelimitationstobepermanent?YesNoIf“no”,pleaseexplainwhenimprovementmaybeexpected:
Page 14 of 14 GLC-01252
e. Required attachments and signature
after you have fully completed this form, attach copies of the following materials:– Office notes for the period of treatment for the last two years– test results showing objective findings– Hospital discharge summaries– consulting physician reports
YourName Degree
Specialty Telephone:Fax:
Address
X ______________________________________________________________________________ __________________________________SignatureofAttendingPhysician(nostamp) Date